Overview

If there are no sperm in the ejaculate (azoospermia), or the numbers/quality are very poor, surgical retrieval of sperm may be required. The selection of the surgical approach depends on a number of factors, but most importantly:

Probability of successful sperm retrieval. This is heavily dependent on the likely cause of azoospermia - the most important distinction is obstructive (e.g. vasectomy) vs. non-obstructive (e.g. Klinefelter's syndrome)

Potential complications of retrieval.

Cost and patient preference.

Every man is different, and the information found at the time of the procedure may alter the intraoperative approach. For example, in men who have had vasectomy sperm can usually be found in the epididymis and therefore a PESA is usually the first choice because of high success rate, simplicity and the low risk of complications. In some circumstances, however, the epididymis will not contain sperm and a TESE is required - this may not be apparant until the PESA is attempted. A TESE is slightly more involved with a longer recovery than a PESA. In all patients, the overall goal is to find a procedure with the right balance of successful retrieval, potential complications and cost to suit you. It is important to note that while sperm can be found in many men there is no guarantee that sperm will be found. Your urologist will discuss the probability of finding sperm based on your individual circumstances and the different surgical approaches to retrieval.

Surgially retrieved sperm almost always require in vitro fertilization (with or without ICSI) to obtain a pregnancy. Therefore, egg retrieval from your partner (or use of a donor egg) is usually required. Your spouses gynecologist/reproductive endocrinologist will discuss the process with you.

Another important consideration in sperm retrieval is whether the sperm will be used 'fresh' or 'frozen'. Using 'fresh' sperm means that once the sperm are retrieved, they are used immediately to fertilize an egg. Using 'frozen' sperm means that the sperm are frozen for future use (see our section on cryopreservation) and then thawed when the eggs are available. When sperm are used fresh any excess sperm are usually frozen for possible future use. In some circumstances, frozen sperm are as good as frozen sperm (including cases when sperm are retrieved after vasectomy). However, in cases where very low numbers or quality of sperm are retieved, the sperm may not survive the freeze-thaw cycle or be usable for egg fertilization. Therefore, if it is likely that only a few sperm will be found we typically recommend using fresh sperm.

Surgical Sperm Acquisition

When no or poor quality sperm are found in the ejaculate, retrival of sperm further 'upstream' is necessary. In most cases, the sperm acquired surgically require the use of IVF with or without ICSI. They cannot be used for intrauterine insemination because of either immaturity of lack of sufficient numbers. It is important to recognize that there is no guarantee that sperm will be found at the time of surgery and that finding sperm does not guarantee a pregnancy or successful delivery of a healthy child. For men with obstructive azospermia (e.g. following vasectomy or with cystic fibrosis), the chances of obstaining sperm approach 100%. In cases of non-obstructive azospermia, Dr. Poon can give you an individualized estimate of the chances of success based on your diagnosis and clinical features.

The terminology for the different types of sperm retreival can be confusing. Here are common-language descriptions for the most commonly performed types of surgical sperm retrieval.

PESA - Percutaneous Epididymal Sperm Aspiration

What is it? Use of a needle to 'suck' sperm from the storage sack attached to the back of the testicle. This is a 'blind' procedure in that individual tubles are not targeted.

When is it done? Highly successful in men with obstruction, though slightly less so than MESA. Can be performed under local anesthetic without an incision and with a rapid recovery. High success rate and relatively low cost make this the initial approach in most men with obstructive azospermia - e.g. following vasectomy or with congenital absence of the vas deferens. In almost all circumnstances, IVF with our without ICSI are required to use sperm harvested in this manner. If a PESA is unsuccessful, we can transition to a TESE at the same sitting.

Preparation and potential complications. Please shave the scrotum before coming for the procedure.You do NOT need to fast prior to this procedure.

Would also recommend that you bring an athletic support or wear tight fitting brief-style underpants. The major potential complication is bleeding and bruising. While a small amount of brusing is relatively common, it is very, very rare to have scrotal bleeding which results in swelling. Limiting activity following the procedure, scrotal support and an ice pack for a day or two should suffice.

MESA - Microscopic Epididymal Sperm Aspiration

What is it? Similar to a PESA, but involves targeting individual epididymal tubules for aspiration. This requires delivering the testis from the scrotum through an 4-6 cm incision, an operating microscope, usually a general anesthetic. As such, it is much more expensive than a PESA with marginally higher success rates.

When is it done? There are not many indications for a MESA since if PESA fails, a TESE an be performed with a similar or higher success rate and with similar risk, but without the requirement for a general anesthetic. In almost all circumnstances, IVF with our without ICSI are required to use sperm harvested in this manner.

Preparation and potential complications. Please shave the scrotum before coming for the procedure. As this procedure requires a general anesthetic, you will need to FAST STARTING THE NIGHT BEFORE THE PROCEDURE and make arrangements to be accompanied home by a friend. You are not permitted to drive for 24 hours after the procedure and taking taxi unaccompanied is not acceptable. If you do not follow these requirements, your procedure will be cancelled and you may be required to pay a cancellation fee.

We recommend that you bring an athletic support or wear tight fitting brief-style underpants. The major potential complication is bleeding and bruising. While a small amount of brusing is relatively common, it is very, very rare to have scrotal bleeding which results in swelling. Other rare complications include spermatocele formation or hydrocele formation. Limiting activity following the procedure, scrotal support and an ice pack for a day or two should suffice.

TESE - TEsticular Sperm Extraction

What is it? Sperm are retrieved directly from the testis itself. This is performed under local anesthetic through a small 1-2 cm cut in the scrotum. Some of the tubules in which sperm are formed are extruded and removed. The total amount of a testis that is removed is usually less than 5%. The sperm must be released from the tubules by special mechanical processing.

When is it done? This is generally used if obstruction is suspected, but no sperm can be retrieved with a PESA (or MESA). It is much less effective for non-obstructive azospermia, including conditions such as Klinefelter's syndrome, Y-chromosome microdeletion and idiopathic (unknown) causes of azospermia.

Preparation and potential complications. Please shave the scrotum before coming for the procedure. You do NOT need to fast prior to the procedure.

We also recommend that you bring an athletic support or wear tight fitting brief-style underpants. The major potential complication is bleeding and bruising. While a small amount of brusing is relatively common, it is very, very rare to have scrotal bleeding which results in swelling. Other rare complications include spermatocele formation or hydrocele formation. Limiting activity following the procedure, scrotal support and an ice pack for a day or two should suffice.

microTESE - Microdissection TEsticular Sperm Extraction

What is it? This is the gold standard treatment for men with non-obstructive azospermia. Dissection of the seminiferous tubules of the testis is performed under a high-powered operating microscope. Tubules which are suspected to contain sperm production are selectively harvested and searched for sperm. Dissection of one or both testes may be required.

When is it done? This technique has the single best chance of finding sperm in cases of non-obstructive azospermia. Even is sperm production is present in non-obstructive azospermia, it tends to be limited. There can be islands of sperm production within the testis which a standard TESE can simply miss by chance. These islands can often be identified based on their microscopic appearance - tubules without sperm production tend to look like uncooked pasta (narrow and dark yellow) whereas those with sperm production often look like cooked pasta (plump and pale yellow). The tubules are about the size of a human hair and doing a thorough assessment means opening up the testis and carefully sifting through the testes. This requires a general anesthetic. The chances of successful sperm retrieval are double that of a standard TESE. Because the number of sperm retrieved are usually small, it is highly recommended that they are used 'fresh' rather than 'frozen' (thawing after cryopreservation).

Preparation and potential complications. Please shave the scrotum before coming for the procedure. As this procedure requires a general anesthetic, you will need to FAST STARTING THE NIGHT BEFORE THE PROCEDURE and make arrangements to be accompanied home by a friend. You are not permitted to drive for 24 hours after the procedure and taking taxi unaccompanied is not acceptable. If you do not follow these requirements, your procedure will be cancelled and you may be required to pay a cancellation fee.

It because the scrotum and testes are opened, it can take a few weeks for the swelling and discomfort to resolve. While swelling, mild bruising and discomfort are common, other complications are fortunately very uncommon occuring in less than 5% of patients. The potential uncommon complications include: bleeding within the scrotum and hematoma formation, infection, a decrease in testosterone production (usually transient and clinically insignificant), hydrocele or spermatocele formation and atrophy (shrinkage or loss) of the testicle.